Chronic Prostatitis

Brief Overview: There are two types of chronic prostatitis. Chronic nonbacterial/inflammatory, and chronic bacterial. For our purposes, will combine each into a general chronic prostatitis format. The primary difference in chronic nonbacterial prostatitis is pelvic/perineal/and/or testicular pain with LUTS, in the absence of any other pathology. Bacterial prostatitis includes symptoms of prostatitis with positive urine cultures and no signs of systemic infection. Hallmark would be recurrent UTI with a single organism.

Prevalence: Low prevalence (1.8%) of nonbacterial prostatitis. Chronic bacterial prostatitis is the most common cause of recurrent UTI in adult males. Prostatitis in general/acute/chronic affects 10-14% of men of all ages and accounts for 2 million OV annually.

• As BPH progresses, obstruction causes reflux of urine into prostatic ducts leading to inflammation. Bacteria are present in these inflamed ducts.
• Most common pathogens are e.coli, enterococcus, klebsiella, pseudomonas. Prostate calculi may serve as a nidus of infection, bacteria enters the calculi and are not easily treated with antibiotics, so symptoms commonly recur.

• Inadequately treated episodes of acute bacterial prostatitis, BPH/bladder outlet obstruction, urethral strictures, catheterization, unprotected intercourse, new sexual partners
• Psychological stress can be an additional risk factor for nonbacterial/inflammatory chronic prostatitis.

Associated Conditions: BPH, sexual dysfunction, STDs, infertility, urethral stricture. For Inflammatory CP-depression, fibromyalgia, and fatigue.

Common Symptoms:

• Suprapubic/low back/scrotal pain, painful ejaculation, sexual dysfunction, LUTS- urgency, frequency, hesitancy, weak/intermittent stream, dysuria.
• Fever and chills are not usual and typically indicate acute bacterial prostatitis.

Physical findings- DRE may reveal tender or boggy prostate, perineal tenderness, and vague pelvic discomfort.

Common Labs, Imaging, and Testing:

• *Urinalysis and culture*- may show blood, leukocytes, and bacteria. Culture may be negative.
• Stamey test- “Gold Standard” for dx chronic prostatitis by collecting isolated cultures of different portions of the urinary tract. Obtained by pre/post prostatic massage urine samples for obtaining bladder and prostatic flora respectively.
• PSA will typically be elevated in presence of infection, and should be avoided.
• Transrectal ultrasound, is not commonly performed, but may show prostatic enlargement or calculi.
• Urodynamics can be considered for pain + LUTS, more inflammatory than bacterial.
• Cystoscopy-not required for diagnosis, but can be considered if other etiology is suspected.

• General- The focus of therapy is symptom relief. Conservative measures can include physical therapy, diet modification (avoiding caffeine, alcohol, spicy foods), and acupuncture. Avoiding prolonged perineal pressure (long car rides, sitting, biking). The goal is to eliminate nidus for infection. See below for med mgt.

• Nonbacterial: Data conflicting for antibiotic use, can consider in antibiotic naïve patients. Assess treatment response after 2-4 weeks. Otherwise, alpha-blockers such as tamsulosin, 5-ARIs such as finasteride, anti-inflammatories, steroids, Gabapentin, muscle relaxants.
• Bacterial- Primarily fluoroquinolones, TMP/SMX, and tetracyclines. Anti-inflammatories and alpha-blockers.

Potential Complications: Recurrent cystitis, epididymitis, urethritis. Infertility. Primarily problems with quality of life. No known predisposition to cancer.

General Health and Lifestyle Guidance: Routine prostate cancer screenings. Again, avoiding foods and beverages that contain caffeine, acid, spice, and alcohol. Supplements such as saw palmetto are popular but found to only be as effective as placebo. Frequent ejaculation in patients with enlarged, congested glands.

• Are you routinely screened for prostate cancer?
• Are you having any irritative voiding symptoms such as urgency, frequency, or dysuria?
• Are you having nausea/vomiting, fever, chills? This may indicate acute infection.
• Are you compliant with your medications for symptom control?
• Do you have any known psychological or neurological conditions? Can contribute to inflammatory/nonbacterial CP.
• Do you take your antibiotics as prescribed, completing the entire course?

• Medication compliance, particularly antibiotics
• Depression screening if chronic symptoms interfere with quality of life
• Keep follow up with urologist and notify if symptoms persist despite treatment.